Pediatric General Surgery Research Articles

USNS COMFORT (T-AH 20) Surgical Services Response to the COVID-19 Pandemic in New York City.

USNS COMFORT (T-AH 20) Surgical Services Response to the COVID-19 Pandemic in New York City.

Opioid Stewardship in Pediatric General Surgery – Approaching Zero

Opioid Stewardship in Pediatric General Surgery – Approaching Zero Department of Pediatric Surgery Thais Calderon, Elizabeth Hedges M.D, Theresa Foito, Marsha Pulhamus, Christopher Gitzelmann M.D., Walter Pegoli Jr M.D., and Derek Wakeman M.D Introduction: Opioid abuse is a public health crisis in North America. An effort to adequately treat pain post-operatively has resulted in over prescription of opioids without fundamental evidence of improved pain management when compared to …

Opioid Stewardship in Pediatric General Surgery – Approaching Zero

Opioid Stewardship in Pediatric General Surgery – Approaching Zero

The first six years of the APSA Travel Fellowship Program: Impact and lessons learned

IntroductionThe American Pediatric Surgical Association (APSA) travel fellowship was established in 2013 to allow pediatric surgeons from low- and middle-income countries to attend the APSA annual meeting. Travel fellows also participated in various clinical and didactic learning experiences during their stay in North America. MethodsPrevious travel fellows completed a survey regarding their motivations for participation in the program, its impact on their practice in their home countries, and suggestions for improvement of the fellowship. ResultsEleven surgeons participated in the travel fellowship and attended the annual APSA meetings in 2013–2018. The response rate for survey completion was 100%. Fellows originated from 9 countries and 3 continents and most fellows worked in government practice (n=8, 73%).Nine fellows (82%) spent >3 weeks participating in additional learning activities such as courses and clinical observerships. The most common reasons for participation were networking (n=11, 100%), learning different ways of providing care (n=10, 90.9%), new procedural techniques (n=9, 81.8%), exposure to a different medical culture (n=10, 90.9%), and engaging in research (n=8, 72.7%). Most of the fellows participated in a structured course: colorectal (n= 6, 55%), laparoscopy (n=2, 18%), oncology (n=2, 18%), leadership skills (n=1, 9%), and safety and quality initiatives (n=1, 9%). Many fellows participated in focused clinical mentorships: general pediatric surgery (n=9, 82%), oncology (n=5, 45%), colorectal (n=3, 27%), neonatal care (n=2, 18%) and laparoscopy (n=2, 18%). Upon return to their countries, fellows reported that they were able to improve a system within their hospital (n=7, 63%), expand their research efforts (n=6, 54%), or implement a quality improvement initiative (n=6, 54%). ConclusionsThe APSA travel fellowship is a valuable resource for pediatric surgeons in low- and middle-income countries. After completion of these travel fellowships, the majority of these fellows have implemented important changes in their hospital’s health systems, including research and quality initiatives, to improve pediatric surgical care in their home countries. Level of evidenceThis is not a clinical study. Therefore, the table that lists levels of evidence for “treatment study”, “prognosis study”, “study of diagnostic test” and “cost effectiveness study” does not apply to this paper.

Curriculum Change Needed: A Decline in Antireflux Surgery in the Pediatric Surgery Fellowship

Case number requirements by the Accreditation Council for Graduate Medical Education (ACGME) have recently changed in general surgery residency and pediatric surgery fellowship. Overall, pediatric surgery fellowship case volumes remain high, but there may be limited exposure to many index cases. We hypothesize that pediatric antireflux surgery is decreasing nationally, and this trend is independent of the fluctuating number of pediatric surgery fellows. A review of publicly available ACGME case reports from 2003 to 2018 was performed. Both open and laparoscopic antireflux surgery cases were evaluated. Analyzed data included average case number per fellow, minimum and maximum case numbers, and number of fellows each year. Simple and multiple linear regression analyses were performed. We identified a significant relationship (P<0.001) between the total number of antireflux procedures and the years of operation. The slope coefficient was -1.45, meaning the number of operations decreased by an average of 1.45 per year from 2003 to 2018 . The number of fellows fluctuated during this time period (range: 24-45). With multiple linear regression analysis, we found that the number of fellows did not affect the decline of antireflux surgery seen over the years (P=0.91). Case numbers continue to be an important topic in ACGME discussions for surgical residency and subspecialty fellowships. Our review has shown a national decline in the number of pediatric antireflux surgeries performed in pediatric surgery fellowship. Identifying additional trends in surgical management of diseases may aid in the evolution of the pediatric surgery curriculum.

The Perioperative Services Response at a Major Children's Hospital During the Peak of the COVID-19 Pandemic in New York City.

The Perioperative Services Response at a Major Children's Hospital During the Peak of the COVID-19 Pandemic in New York City.

Efficacy of regional anaesthesia for paediatric surgery: Experience from a surgical expedition

Background: In developing countries where resources are scarce and health care financing is essentially by out-of-pocket payment, a surgical expedition is often a huge economic relief. Children are a category of the vulnerable group that can benefit from such exercises. However, an anaesthesia technique that is economical in both human and material resources should be explored, Objective: To describe the outcome of regional anaesthesia techniques during a surgical expedition for paediatric patients. Methods: Children aged 6 months to 16 years, who had been previously screened for free surgery in different surgical specialities, were recruited for the study. Results: Fifty-six (56) children were screened but only 35 were recruited for the surgical expedition. There were nineteen (19) males and sixteen (16) females with a male to female ratio of 1.5:1. Surgical procedures covered surgical specialities such as orthopaedics, plastic and general paediatric surgery. All the patients had one form of regional technique and/or peripheral nerve blocks. There were no intra-operative or post-operative anaesthetic complications up to a period of 30-days while on follow-up care. Conclusion: Regional anaesthesia is safe and a cheap choice of anaesthesia in children during surgical expeditions.

Short-term surgical trips: local collaboration and its effects on complications and patient satisfaction.

Short-term surgical missions can provide communities in need with desired expertise; however, it is uncertain who will manage the complications after visiting experts leave. Poor outcomes, decreased patient satisfaction, and tension on the healthcare system develop when local providers, often excluded from the initial patient care, are unable to cope with subsequent morbidity. Two-year retrospective review of pediatric general, plastic, and reconstructive surgery, and urology cases performed by a relief organization in the developing world. Case complexity and postoperative complications were analyzed. Phone interviews conducted with patients/families to quantify postoperative outcomes and satisfaction. 474 surgeries were performed on pediatric patients with 60% response rate. Respondents stratified into three levels of complexity: 159 simple, 72 intermediate, and 54 advanced surgeries. Six (2.1%) high-level complications occurred. No association between the complexity of the surgery and the occurrence of a complications. 83.5% were satisfied with outcomes and > 92% were happy with the provided support. Facilitating visiting and local surgeons performing cases together increases the expertise of local providers, strengthens infrastructure, and establishes clear follow-up. Despite complications, patients and families continued to recommend care to family and friends by the relief organization and were happy with support from local providers. Engaging local providers is the gold-standard for short-term trips.

Vascular surgery's identity

Vascular surgery's identity

Kids, cameras, and acute care: Minimally invasive management in pediatric emergency general surgery.

Kids, cameras, and acute care: Minimally invasive management in pediatric emergency general surgery.

A138 CONCEPTUALIZING ENTRUSTMENT IN ENDOSCOPIC TRAINING

Abstract Background Competency-based medical education (CBME), an educational paradigm that prioritizes development of measurable skills over time in training, is currently being instituted across North American residency training programs. A fundamental goal of CBME is entrustment – the process whereby supervisors come to trust trainees to perform specific tasks without supervision. How entrustment decisions are made with respect to endoscopic training has not been elucidated. Aims We aimed to: (1) identify the factors trainers consider in making endoscopic entrustment decisions and (2) characterize this entrustment decision-making process. Methods A qualitative, interview-based study was conducted using a constructivist grounded theory approach. A purposive sample of endoscopic trainers from across North America were recruited with representation from adult and pediatric gastroenterology, general surgery, and family medicine. Consenting trainers undertook audio-recorded, semi-structured interviews designed to elicit how they make endoscopic entrustment decisions and the factors they consider in making these decisions. Interview transcripts were analyzed using constant comparison, and themes were identified iteratively, working toward an explanatory framework that highlighted relationships among themes. Recruitment continued alongside analysis until theoretical saturation, determined as the point at which no new insights arose from the data. Results Twenty-three trainer interviews were conducted, comprising 8 (34.8%) with adult gastroenterologists, 7 (30.4%) with general surgeons, 6 (26.1%) with pediatric gastroenterologists, and 2 (8.7%) with family physicians. Of those interviewed, 10 (43.5%) practiced in Canada and 13 (56.5%) practiced in the United States. Interviewees conceptualized entrustment as a continuum rather than a binary (yes/no) decision. Entrustment decision-making was found to be a complex process, involving factors related to the: (1) trainee (insight into their own abilities, technical skills, nontechnical skills); (2) trainer (perceived self-competence, disposition, prioritization of trainee learning relative to competing demands); (3) trainer-trainee relationship (duration of exposure); (4) patient (acuity, comorbidity, comfort); (5) procedure (complexity); and (6) environment (time constraints, equipment, presence of anesthesiologist). These factors directly and indirectly contributed to the themes of trainee readiness, trainer comfort, and patient safety, which collectively predicted endoscopic entrustment decisions. Conclusions Entrustment in endoscopic training is a complex process incorporating multiple factors. Clarification of this process and identification of predictive factors informs the development of endoscopic assessment tools and curricula uniquely suited to CBME. Funding Agencies CAG

Pediatric thyroidectomies: A surgical subspecialty comparison

ObjectiveThis study aims to establish the typical population, safety, and outcomes of pediatric thyroidectomies, specifically identifying surgical complication rates. Furthermore, the study compares management and complication differences between the two specialties that most often manage these patients - Pediatric General Surgery and Otolaryngology. MethodsNational Surgical Quality Improvement Program – Pediatrics (NSQIP-P) data between the years of 2012 and 2016 was reviewed and analyzed for patient characteristics, perioperative course and outcomes. Sub-group analysis was used to compare groups based on surgeon sub-specialty: Otolaryngology or Pediatric General Surgery. ResultsThe study identified 516 cases pediatric patients operated on by Pediatric Otolaryngology (229; 44.4%) and Pediatric General Surgery (287; 55.6%). Overall, rates of surgical and medical adverse events were low (1.2% and 0.7%, respectively). Upon univariate analysis, there were no differences between specialties in surgical adverse events (p = 1.000), medical adverse events (p = 0.196), reoperation (p = 0.505), or readmission (p = 0.262). Indication for surgery differed between specialties, with benign neoplasm more common in the Pediatric Otolaryngology group (48.9% vs. 35.2%), and thyrotoxicosis more common in the Pediatric General Surgery group (43.9% vs. 23.1%) (p < 0.001). Compared to cases done by Otolaryngology, Pediatric General Surgery was independently associated with a shorter operative time (B: −31.583 min [95% CI: −42.802 to −20.364]; p < 0.001). ConclusionThyroidectomy in the pediatric population is a safe procedure with no differences in adverse outcomes noted when comparing Pediatric General Surgeons to Pediatric Otolaryngologists. Pediatric General Surgeons were observed to have a significantly shorter operative time.

Cerrahi Alan İnfeksiyonlarının Değerlendirilmesi ve Risk Faktörlerinin Analizi

Surgical site infections (SSI) extend the patient’s length of stay, causing unnecessary complications and increase mortality, morbidity and cost. In each hospital, these infections take place in hospital infection surveillance and show changes specific to hospitals. In this study, the files of 402 patients; hospitalized between 2016 and 2018 in the surgical clinics of the Health Sciences University Bursa High Specialization Training and Research Hospital were analyzed retrospectively in terms of SSI, patient profile, length of stay, underlying diseases, risk factors and causative microorganisms. In the study, patients in gynecology and obstetrics, pediatric surgery, cardiovascular surgery, orthopedics, general surgery, urology, and neurosurgery services were included in the surgeries that were followed up on the basis of the procedures in accordance with the decisions of the infection control committee. The most frequently isolated microorganisms in SSI were coagulase negative staphylococci (14.7 %) Escherichia coli (11.7 %), Staphylococcus aureus (6 %) Klebsiella spp. (7 %) and Pseudomonas spp. (3.5 %), while the rate of culture negative SSI cases was determined as (41.5 %). In statistical analysis; presence of a foreign body prosthesis, coronary artery disease, diabetes mellitus, hypertension, hemodialysis, H2 receptor antagonist use, chest tube, peripheral artery catheter, central venous catheter, nasogastric catheter, surgical drain, transfusion, urinary catheter, peripheral venous catheter, mechanical ventilation and endotracheal intubation were statistically significant in the development of SSI. In the analyzes on length of stay, it was found that the length of stay significantly increased as the depth increased in the SSI classification. Identifying risk factors for SSI is critical to reduce the incidence of SSI and identify high-risk patient populations that may require more surveillance for postoperative infection and to develop quality improvement strategies and infection control interventions.

Laparoscopic-assisted management of paediatric intra-abdominal lymphatic malformations

Lymphatic malformations (LMs) are low-flow vascular anomalies with treatment modalities that include conservative, sclerotherapy, oral therapeutic agents and surgical excision. The use of laparoscopy combined with interventional radiology has not previously been described. We report our multidisciplinary (MDT) approach to the management of these lesions. All complex paediatric LM referrals are discussed at our vascular MDT that spans across general paediatric surgery, interventional radiology (IR), plastics, orthopaedics, ENT, and dermatology. Intra-abdominal LM’s undergo an initial USS followed by contrast-enhanced MRI to confirm diagnosis and delineate the nature of the lesion. Our first-line treatment has previously been US-guided sclerotherapy. More recently, we have changed our approach to perform an intra-operative assessment of these lesions combined with IR to confirm the diagnosis and assess their resectability. Four patients have undergone combined assessment with our IR team in the last 24 months ranging from 1 to 7 years of age. Two lesions were found to involve the distal ileum, one proximal jejunum and one greater omentum. In all cases, the lesions were excised following initial laparoscopic assessment combined with IR-guided drainage. There have been no complications encountered in these four patients and none have had a recurrence till date. Primary laparoscopic assessment of an intra-abdominal LM is feasible and enables the confirmation of the diagnosis and assessment of resectability. Morbidity from the use of sclerosant agents and the repeated use of general anaesthesia can also potentially be avoided using this technique.

Application of the Clavien-Dindo classification to a pediatric surgical network

IntroductionA comprehensive validated system to evaluate surgical complications is required in our specialty to facilitate comparison and audit. The Clavien-Dindo (CD) classification of post-surgical complications was originally described in an adult general surgical setting in 1992 and has become widely used. We aimed to apply this to a pediatric surgical setting. MethodsData were collected on emergency and elective surgical activity together with complications in a prospective audit over a recent 4-month period in three geographical conjoined regional pediatric surgical units (including two major trauma centres). Briefly the CD classification codes complications according to degree of harm and magnitude of intervention required [I – V (death) with III and IV sub-divided according to whether general anesthesia was needed]. Length of stay and mode of admission were recorded. Data are given as median (range). Non-parametric comparison was used, and a p value of <0.05 was regarded as significant. ResultsDuring the period JULY – OCT 2018 (inclusive), there were 1822 admissions (elective, n = 1186: emergency, n = 636) and 1556 operations (elective, n = 1189, and of these 393 were urological). There were 69 patient complications: CDI (n = 7), CD-II (n = 19), CD-IIIa (n = 4), CD-IIIb (n = 28), CD-IV (n = 4), CD-V (n = 7). Deaths were principally in neonates and due to NEC (n = 6) at 2.5 (1–140) days post-operatively. There was a single post-traumatic death in an adolescent. LOS was 9 (0–217) days in CD I-IV.The incidence of any complication was 4.4%, of serious complication (defined as ≥CD III) 2.6% (A = 2.1%, B = 2.0%, and C = 3.2%: p = 0.16), and of death 0.45%. The most frequent complications were wound infection (n = 12) and post-appendicectomy collections/abscess (n = 10). ConclusionsThis appears to be the 1st report of the C-D classification in a general pediatric surgery network and can be considered a benchmark. The risk of death or serious harm is very low in such a practice. Type of StudyProspective Cohort Study. Level of EvidenceIIb.

Trends in the use of surgical antibiotic prophylaxis in general pediatric surgery: Are we missing the mark for both stewardship and infection prevention?

BackgroundThe purpose of this study was to assess compliance with antimicrobial spectrum guidelines in the use of surgical antibiotic prophylaxis (SAP) in pediatric surgery. MethodsA retrospective cohort study of children undergoing elective clean-contaminated and clean surgical procedures with foreign body implantation using the Pediatric Health Information System database (10/2015–6/2018) was performed. Compliance rates with consensus guidelines surrounding appropriate spectrum of SAP coverage were calculated for each procedure. Undertreatment was defined as the use of SAP with inappropriately narrow coverage (or omission altogether), while overtreatment was defined as inappropriately broad coverage. ResultsEight procedure groups including a total of 15,708 patients were included. Overall, 44% of cases received inappropriate prophylaxis, of which 58% were considered undertreatment and 42% overtreatment. Procedures with the highest rates of overtreatment included small bowel procedures (77%), colorectal procedures (29%), and hepatobiliary procedures (20%), while the highest rates of undertreatment were associated with placement of tunneled central venous catheters and ports (43%), hepatobiliary procedures (24%), and colorectal procedures (20%). ConclusionNoncompliance with the recommended spectrum of coverage for surgical antibiotic prophylaxis is common in pediatric surgery, with both over and undertreatment being common themes. Improved compliance is needed to optimize both antibiotic stewardship and infection prevention. Type of studyTreatment study. Level of evidenceLevel III.

2019 Canadian Surgery Forum Abstracts.

# 01. The future of general surgery training: a Canadian resident nationwide Delphi consensus statement {#article-title-2} Various pedagogical models have been introduced in an attempt to improve and restructure surgical training, but significant obstacles remain. Before implementing national

Engaging the patient and family in the surgical safety process utilizing

BackgroundOwing to the vulnerable nature of children, parental/caregiver engagement in surgical safety is a crucial aspect of care. Historically, the surgical safety process has been isolated from parent involvement. The digital, tablet-based surgical safety application, SafeStart, requires parent participation and provides multiple instances of verification of patient safety information from preoperative clinic visit, to perioperative care, and into the operating room. MethodThe SafeStart application was utilized for 100 pediatric general surgery patients in an IRB approved prospective study. Parent assessments of the surgical consent and safety processes were collected in pre- and postoperative surveys with a 100% response rate. Standard consent forms were used and compared as a control. ResultsOnly 31% of parents had knowledge of the surgical safety checklist process prior to their exposure to the study. 96% of the parents reported that the SafeStart patient portal was easy to use. A majority would prefer SafeStart to the standard consent process. ConclusionThe SafeStart program connected the surgical safety process from the preoperative clinic visit through postoperative care. Parent's preferred SafeStart to the standard surgical safety checklist and consent process, felt that they were instrumental in protecting their child's safety, and would recommend SafeStart for the surgical care of others. Level of evidenceII

Rural health, telemedicine and access for pediatric surgery.

Access to care for children requiring pediatric general or specialty surgery or trauma care who live in rural areas remains a challenge in the United States. The expertise of specialists in tertiary centers can be extended to rural and underserved areas using telemedicine. There are challenges to making these resources available that need to be methodically approached to facilitate appropriate relationships between hospitals and providers. Programs, such as the National Pediatric Readiness Project and the HRSA Emergency Medical Services for Children Program enhance the capability of the emergency care system to function optimally, keep children at the home hospital if resources are available, facilitate transfer of patients and relationship building, and develop necessary transfer protocols and guidelines between hospitals. Telehealth services have the potential to enhance the reach of tertiary care for children in rural and underserved areas where surgical and trauma specialty care is not readily available, particularly when used to augment the objectives of national programs.

Reliability testing of a modified MISTELS score using a low-cost trainer box

BackgroundTraining programs such as the fundamentals of laparoscopic surgery (FLS) that are based on simulation are being currently used in several western countries. FLS allows skill acquisition and evaluation of competency in laparoscopic surgery. On the practical side, evaluation is determined by the MISTELS metrics (MISTELS is the acronym for the McGill inanimate system for training and evaluation of laparoscopic skills).This training program may be modified so that it can be implemented in countries with limited resources using a low-cost trainer box. Would the use of a low-cost trainer box alter the reliability of the MISTELS score?Objective of studyThe aim of the study was to evaluate the reliability of a modified MISTELS using a low-cost trainer box.MethodsIt was a prospective study carried out at Habib Thameur hospital in Tunis (Tunisia), between April 2016 and August 2016. The study involved residents from different surgical specialties in the departments of general surgery and paediatric surgery of the hospital during 2015 and 2016.This study assessed the reliability of a modified MISTELS system (Only three tasks were performed out of the five tasks used in the original MISTELS system). Evaluation was based on Cronbach’s alpha and intraclass correlation coefficients (ICC).A low-cost trainer box was designed and constructed. The residents included in the study performed three series of three tasks using this trainer box. The first series was scored by two trained raters to evaluate inter-rater reliability. The two-other series were successively performed to evaluate test-retest reliability.ResultsThe internal consistency, assessed by Cronbach’s alpha, was at 0.929 which is an acceptable score. As for inter-rater and test-retest reliabilities that were assessed by ICCs, they yielded excellent scores that were at 1 and 0.95 (95% CI, 0.891–0.978) respectively.ConclusionsThe reliability of a modified MISTELS is not altered by the use of a low-cost trainer box. The score of the modified MISTELS is a reliable score for evaluating technical skills of surgical residents using a low-cost trainer box.